Client • Managed health care company offering clinical and preventive care programs to commercial, government and private health insurers. Challenge • Low rejection rates for pre-processed claims, minimizing the potential for impact on utilization patterns and healthcare spend • Unclear criteria that can be overridden, minimizing the robustness of medical necessity decisions Solutions • InterQual® Criteria • CareEnhance® Review Manager Enterprise Results • An increase in rejections by nurses from less than 1% to approximately 12% • An increase in rejection after physician review of approximately 4% from less than 1% Community Health Solutions Makes the Most of Every Healthcare Dollar by Switching to InterQual Criteria and CareEnhance Review Manager Enterprise Community H

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